AFP Employment Application

DRIVER EMPLOYMENT APPLICATION

SEM LOGISTICS SOLUTIONS LLC - An Equal Opportunity Employer
Full Name*

First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number*
Must contain 9 digits
Applying for Position*
Date Available for Work*

MonthDayYear
Date
Type of work sought?*

Full TimePart TimeTemporary
Do you have legal right to work in the United States?*

YesNo
Will you now or in the future require sponsorship by this Company to attain or maintain your employment status?*

YesNo
How did you hear about this positions (employee referral, ad, web posting, etc.?)
Note: If hired, you must complete Section 1 on Form I-9 required by the U.S. Immigration and Naturalization Service no later thanfirst day of work and provide the documentation required by Section 2 no later than three (3) business days after you start work. Acopy of the back of Form I-9, listing acceptable documentation, is available.

Thank you for your interest in employment with SEM Logistics Solutions. SEM is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant on the basis of age, sex, sexual orientation, gender, gender identity or expression, race, color, creed, religion, ethnicity, national origin, alienage or citizenship, disability, marital status, familial status, genetic information, uniform service or veteran status or any other legally protected basis under applicable federal, state or local laws, regulations or ordinances. The Company will provide reasonable accommodations to allow an applicant to participate in the application and hiring process if requested. Please inform us if you need assistance completing any forms or to otherwise participate in the application process.

Previous Three Years Residency

Attach additional sheet if more space is needed*

	STREET	CITY	STATE	ZIP	# OF YEARS AT ADDRESS
CURRENT
MAILING
PREVIOUS
PREVIOUS
PREVIOUS

License Information*

	STATE	LICENSE #	TYPE/CLASS	ENDORSEMENTS	EXPIRATION DATE

Previously Held Licenses

	STATE	LICENSE #	TYPE/CLASS	ENDORSEMENTS	EXPIRATION DATE

Driving Experience*

	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC)	DATE FROM	DATE TO	APPROX # OF MILES (TOTAL)
Straight Truck
Tractor & Semi-Trailer
Tractor & 2
Tractor & Tanker
Other

Accident Record for the Past 3 Years

	Date	Nature pf Accident (Head-on, rear-end, upset, etc)	# Fatalities	# Injuries	Chemical Spills

Attach additional sheet if more space is needed. Select this option if none.

N/A
Additional Sheet

Browse Files

Cancelof

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

	Date Convicted (Month/Year)	Violation	State of Violation	Penalty (Forfeited bond, collateral and/or points)

Attach additional sheet if more space is needed. Select this option if none.

N/A
Additional Sheet

Browse Files

Cancelof
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

YesNo
If yes, explain:
Has any license, permit, or privilege ever been suspended or revoked?

YesNo
If yes, explain:

Second (Most Recent) Employer

Employer Name

Street Address

CityState

Phone Number
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Reason for Leaving
Explain any gaps in employment (include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YesNo

Third (Most Recent) Employer

Employer Name

Street Address

CityState

Phone Number
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Reason for Leaving
Explain any gaps in employment (include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YesNo
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YesNo

Education*

	Name & Location	Course of Study	Year Completed	Graduated
High School
College
Other

Other Qualifications
Please list any other qualifications that you have and which you believe should be considered.

APPLICANT CERTIFICATION

CERTIFICATION - PLEASE READ CAREFULLY BEFORE SIGNING
I consent to and authorize the Company to contact my former employers, and any and all other persons and organizations for information bearing upon my qualifications for employment. Unless I noted otherwise, I further authorize the listed employers, schools, and personal references to give the Company (without further notice to me) any and all information about my previous employment and education, along with other pertinent information they may have and hereby waive any actions which I may have against either party/parties for providing a reference as part of this application process. I understand that any employment or offer of employment arising from this Application for Employment will be subject to satisfactory verification of all job qualifications and information contained in this Application for Employment, which may include academic credentials, licenses, professional designations, references, credit and employment history, motor vehicles and other background checks, to the extent permitted by and in accordance with applicable law.
(Please initial here to indicate that you have read and understand the above paragraph.)*
I expressly agree and understand that completion of this application is a preliminary step to employment. It does not obligate the Company to offer me employment or for me to accept employment. I further agree and understand that in the event I am employed by the Company, my employment with the Company will be “at will.” This means that my employment is not for a specified term and that it may be terminated by the Company or me at any time, for any reason, with or without cause or notice. I understand that no document or any statement of any employee of the Company constitutes a contract of employment between me and the Company that in any way alters or changes my employment at will status. I further understand that the at-will nature of my employment cannot be changed, on an individual or collective basis, except by a formal written contract, stating it is a contract of employment, signed by the President/CEO of the Company. I understand that this Application for Employment does not constitute an agreement or contract for employment between me and the Company.
(Please initial here to indicate that you have read and understand the above paragraph.)*
In the event I am employed by the Company, I understand that I will be expected to comply with all rules and regulations as set forth in the Company’s policies and in any communications made to me. I understand that while the company makes every effort to accommodate individual preferences, business needs may make the following necessary: overtime; shift work; a rotating work schedule; a work schedule that includes weekend work.
(Please initial here to indicate that you have read and understand the above paragraph.)*
By my signature below, I certify under penalty of perjury that all of the foregoing information is true and complete, and I understand that
any falsification or omission of information may result in denial of employment; or, if I am employed by the Company, may result in termination regardless of the time lapse before discovery.

ARIZONA APPLICANTS ONLY: THE SMOKE-FREE ARIZONA ACT, A.R.S. § 36-601.01, PROHIBITS SMOKING IN PLACES OF EMPLOYMENT AND WITHIN 20 FEET OF ALL ENTRANCES, OPEN WINDOWS, OR VENTILATION SYSTEMS.

CALIFORNIA APPLICANTS ONLY: I understand the Company may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics, etc. during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the Company.

MARYLAND APPLICANTS ONLY: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

MASSACHUSETTS APPLICANTS ONLY: IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.

MONTANA APPLICANTS ONLY: THE EMPLOYMENT RELATIONSHIP IS GOVERNED BY THE WRONGFUL DISCHARGE FROM EMPLOYMENT ACT. MONT. CODE ANN. § 39-2-901.

RHODE ISLAND APPLICANTS ONLY: IF YOU PROVIDE FALSE INFORMATION ABOUT YOUR ABILITY TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB, WITH OR WITHOUT ACCOMMODATIONS, YOU MAY BE BARRED FROM FILING A CLAIM UNDER THE PROVISIONS OF THE WORKERS’ COMPENSATION ACT OF THE STATE OF RHODE ISLAND.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be
contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my
knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier
Safety Regulations
Signature*

Clear
Date

MonthDayYear
Date
Name (Please Print)*
Should be Empty:

DRIVER EMPLOYMENT APPLICATION

Previous Three Years Residency

Employment History

APPLICANT CERTIFICATION